Research
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Thank you for agreeing to complete this questionnaire. Please read each question carefully and make the selection that is most correct for you. ALL OF YOUR ANSWERS are important to us! ALL OF YOUR ANSWERS will be kept confidential. First, we would like to ask a few questions about your background.
Please circle the most appropriate answer or fill in the appropriate blanks for the background questions below.
1.
What is your age? Years
2.
Are you male or female? a. Male b. Female
3.
What is your current weight? lbs
4.
What is your current height? ft. in.
5.
Are you a U.S. citizen?
6.
What is your marital status? a. b. c.
Single, never married a. Yes
Married, or living together
Separated/divorced/widowed b. No
7.
How many children do you have?
8.
Are you currently pregnant? a. Yes b. No c. Not Applicable
9.
Where were you born? a. b. c.
In the United States
In Africa
In the Caribbean d. Other, please specify
10.
When growing up (about age 12), in what area of the world did you live most of the time? a. In the United States b. c. d.
In Africa
In the Caribbean
Other, please specify
11.
Where was your mother born? a. b.
In the United States
In Africa c. d. e.
In the Caribbean
Other, please specify
I don’t know
12.
Where was your father born? a. In the United States b. c.
In Africa
In the Caribbean d. e.
Other, please specify
I don’t know
13.
Did your mother graduate from college? a. Yes b. No
14.
Did your father graduate from college? a. Yes b. No
15. When you were growing up (about age 12), what was your mother’s occupation? a. b. c.
Please specify _______________________________
My mother did not work at that time
I don’t know/not applicable
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16. When you were growing up (about age 12), what was your father’s occupation? a. b. c.
Please specify _______________________________
My father did not work at that time
I don’t know/not applicable
17. When you were growing up (about age 12), did your family own their home? a.
b.
c.
Yes
No
I don’t know
18. When you were growing up (about age 12), did your family have trouble
‘making ends meet’ with the available finances?
Yes a.
b.
c.
No
I don’t know
19.
With whom do you currently live? a.
Family members b.
Friends/Classmates c.
Dorm mates d.
I live alone
20.
Which of the following are sources of income for you? (Circle any that apply) a.
Employment b.
Family Support c.
Financial Aid d.
Savings or investments
21.
What is your combined annual income from all of these sources? a. Less than $ 20,000 per year b. $ 20, 001 to 40,000 per year c. $ 40,001 to 60,000 per year e.
$ 60,001 to 80,000 per year f.
$ 80,001 to 100,000 per year e. More than $ 100,000 per year
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22.
What is your major? Please specify
In which of the following schools a.
College of Liberal Arts b.
School of Business and Management c.
School of Computer, Mathematical and Natural Sciences d.
School of Education and Urban Studies e.
School of Engineering f.
Institute of Architecture and Planning
23.
What is your overall GPA? Please specify
24.
What are your plans for employment following graduation? a. Work/apply for a position in my major field b. Work/apply for a position outside of my major field c. I will not be working or looking for work d. Don’t know
In this section, we would like to ask questions about your health and weight.
25.
Compared to other people your age, would you say that your health is a. excellent b. very good c. good d. fair e. poor
26. Has a physician ever diagnosed you with high blood pressure? a.
Yes b.
No c.
I don’t know
27. Has a physician ever diagnosed you with diabetes? a.
Yes b.
No c.
I don’t know
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28. Has a physician ever diagnosed you with cancer? a.
Yes b.
No c.
I don’t know
29.
Has a physician ever diagnosed you with any type of heart disease? a.
Yes b.
No c.
I don’t know
30. Has a physician ever diagnosed you with breathing problems such as asthma? a.
Yes b.
No c.
I don’t know
31.
While in college, did you ever receive support services as a student with a disability? a.
Yes b.
No c.
I don’t know
32.
Do you consider yourself to be overweight? a.
Yes b.
No c.
I don’t know
33 . Do you consider yourself to be obese? a.
Yes b.
No c.
I don’t know
34. Has a doctor ever told you that you should lose weight? a.
Yes b.
No c.
I don’t know
35.
How much would you like to weigh? lbs
36.
What do you believe that your healthy weight should be?
lbs
37.
Did your weight change during your years in college? a. b.
Yes Increased lbs
Yes Decreased lbs c. Did not change d.
Don’t Know
38.
Are you currently trying to lose weight? a. b. c.
Yes
No
Don’t know
39.
If dieting is part of your effort to lose weight, which method are you using? a.
Just not eating as much b.
Avoiding sugar c.
Avoiding fat d.
Using a special weight loss formula (i.e. Slim Fast) e.
Using a special diet (i.e. Atkins, The Zone, etc.) f.
Joined a program (i.e. Weight Watchers, Jenny
Craig, Overeaters Anonymous) g.
Using a prescribed diet from a physician h.
Using an appetite suppressant i.
I am not dieting
40.
Are you using physical activity or exercise to lose weight? a.
Yes b.
No c.
Don’t know
41.
Have you EVER IN THE PAST gone on a diet to lose weight? a.
Yes b.
No c.
I don’t know
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42.
If you have tried to lose weight IN THE PAST, which method or diet did you use (Circle all that apply) a.
Just didn’t eat as much b.
Avoided sugar c.
Avoided fat d.
Used a special weight loss formula (i.e. Slim Fast) e.
Used a special diet (i.e. Atkins, The Zone, etc.) f.
Joined a program (i.e. Weight Watchers, Jenny Craig,
Overeaters Anonymous) g.
Prescribed diet from physician h.
Used an appetite suppressant i.
I have not dieted
43.
How old were you when you first started dieting to lose weight?
Years of age
_____________ I have not dieted
44.
Are you currently trying to gain weight? a.
Yes b.
No c.
Don’t know
45.
In your household, who usually does the grocery shopping? a.
You b.
Family c.
Other
Circle the word that best describes your feelings about your weight.
46. Losing weight would make me more attractive
Strongly
Agree a
Agree Undecided Disagree b c d
Strongly
Disagree e a a b b c c d d e e
47. Gaining weight would make me more attractive
48.
I have large bones and will never weigh what I “should”
49. My weight affects my ability to exercise
50. In order to stay healthy, I should lose weight
51. In order to stay healthy, I should gain weight
52. In order to stay healthy, I should maintain my current weight
53. In ten years, I expect to weigh more than I do now
54. When it comes to my weight, my family always tells me what to do
55. My weight affects whether people want to be friends with me
56. I get angry whenever friends give me advice or express their opinions about my weight
57. My weight affects whether people like me or not a a a a a a a a a b b b b b b b b b c c c c c c c c c d d d d d d d d d e e e e e e e e e
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58. Because of my weight people often treat me differently
59. My weight effects whether or not I am asked to go out on dates or come to a party
60. Because of my weight, close friends don’t push me to do things
61. I am unsure if my weight condition is getting better or worse
62. I can generally predict the course of my weight gain
63. I am at greater risk for developing heart disease because of my weight
64. I am at greater risk of developing cancer because of my weight
65. I am at greater risk for developing diabetes because of my weight
66. My weight gets in the way of meeting new people
67.
When it comes to my weight, my friends don’t understand what I go through
68.
Because of my weight, I don’t have the energy to do what I want
69. My weight does not stand in the way of what I want to do
70. Because of my weight, other people think I am lazy
71. Other people think I use my weight as an excuse not to do things
72. Because of my weight, I have to work hard to prove myself to others
73. My weight gets in the way of keeping friends of the opposite sex
74. Because of my weight, people in authority treat me differently
75. My weight keeps me from attending social gatherings
76. Other people do not recognize my achievements because of my weight
77. My weight is the most significant thing in my life
78. I am concerned about my future health due to my weight
Strongly
Agree a a a a a a a a a a a a a a a a a a a a a
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Agree Undecided Disagree b b b b b b b b b b b b b b b b b b b b b c c c c c c c c c c c c c c c c c c c c c d d d d d d d d d d d d d d d d d d d d d
Strongly
Disagree e e e e e e e e e e e e e e e e e e e e e
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79.
My significant other encourages me to a.
Lose weight b.
Gain weight c.
Stay the way that I am d.
Not applicable
80. My family encourages me to a.
Lose weight b.
Gain weight c.
Stay the way that I am d.
Not applicable
81.
Most men prefer women who are a.
Slightly underweight b.
Normal weight c.
Slightly overweight d.
Doesn’t matter
82.
Most women prefer men who are a.
Slightly underweight b.
Normal weight c.
Slightly overweight d.
Doesn’t matter
83.
Where do you learn about nutrition and health? (Circle any that apply) a.
Physician, dietitian, or other health professional b.
Health food store c.
Television, magazines, or books d.
The gym e.
Family or friends f.
School/Internet g.
I don’t know
84.
Which of the following over-the counter products do you take? (Circle any that apply) a.
Echinacea b.
Ginkgo Biloba c.
Saw Palmetto d.
St. John’s Wort e.
Ma Huang f.
Ephedrine g.
Pacmar h.
Other herbs please specify _________________________ i.
None
85.
What types of professionals do you use as health care providers? a.
Physician b.
Chiropractor c.
Acupuncturist d.
Psychologist e.
Minister f.
Other g.
None
86.
Which food programs have you utilized during the past 5 years? a.
Food stamps b.
WIC c.
Daycare or school lunch for your school children d.
Food pantries, shelters, or social service agencies e.
Food assistance from family or friends f.
None
87.
Are you able to buy food on most days? a.
Yes b.
No c.
It is never predictable d.
Don’t know
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About how often do you eat the following foods from restaurants or carryouts?
Never Occasionally
(monthly)
Often
(weekly)
88.
Fried Chicken (Chicken Boxes)
89.
Burgers
90. Pizza
91.
French Fries
92.
Chinese Food
93.
Mexican Food a a a a a a
94.
Fried Fish
95.
Sub Sandwiches a a
96.
How many soft drinks, sodas, juices, or other sweetened beverages do you drink? a.
Less than 1 per day b.
1-2 day c.
More than 2 a day
Below are topics to help us learn about your eating habits. b b b b b b b b c c c c c c c c
Several times a week d d d d d d d d
97.
How much do you drink in a typical serving? a.
12 oz (1can) b.
20 oz (1 bottle) c.
32-64 oz (large store mug) d.
I don’t drink soft drinks or sweet beverages
Read each item and think if you agree or disagree that the item describes you and your eating habits.
Circle the appropriate feeling you have for each question.
If a statement does not apply to you (for example a question asks about what you do at work and you do not have a job), then mark the Strongly Disagree box.
98.
I stop for a fast food breakfast on the way to school or work.
Strongly
Disagree a
Disagree Neutral
N/A b c
Agree Strongly
Agree d e
99.
My emotions affect what and how much I eat.
100.
I use low-fat food products. a a b b c c d d e e
101.
I carefully watch the portion sizes of my foods. a b c d e
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102.
I buy snacks from vending machines.
103.
I choose healthy foods to prevent heart disease.
104.
I eat meatless meals from time to time because I think that it is healthier for me.
105.
I take time to plan meals for the coming week.
106.
When I buy snack foods, I eat until I have finished the whole package.
107.
I eat for comfort.
Strongly
Disagree a
Disagree Neutral
N/A b c
Agree Strongly
Agree d e a a a a a b b b b b c c c c c d d d d d e e e e e
108.
I am a snacker.
109.
I count fat grams.
110.
I eat cookies, candy bars, or ice cream in place of dinner.
111.
When I don’t plan meals, I eat fast food.
112.
I eat when I’m upset.
113.
I buy meat every time I go to the grocery store.
114.
I snack more at night.
115.
I rarely eat breakfast.
116.
I try to limit my intake of red meat (beef and pork).
117.
When I am in a bad mood, I eat whatever I feel like eating.
118.
I never know what I am going to eat for supper when I get up in the morning.
119.
I snack two to three times every day.
120.
Fish and poultry are the only meats I eat.
121.
When I am upset, I tend to stop eating.
122.
I like to eat vegetables seasoned with fatty meat.
123.
If I eat a larger than usual lunch, I will skip sugar.
124.
I take a shopping list to the store.
125. If I am bored, I will snack more
126.
I eat at church socials. a a b b b b b b b b b b b b b b b b b a a a a a a a a a a a a a a a a a b b c c d d d d d d d d d d d d d d d d d c c c c c c c c c c c c c c c c c d d e e e e e e e e e e e e e e e e e e e
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127.
I am very conscious of how much fat is in the food I eat.
128.
I usually keep cookies in the house.
129.
I have a serving of meat at every meal.
130.
I associate success with food.
131.
A complete meal includes meat, a starch, a vegetable and bread.
132.
On Sunday, I eat a large meal with my family.
134.
Instead of planning meals, I choose what is available and what I feel like eating.
135.
If I eat a larger than usual lunch, I will replace supper with a snack.
136.
If I am busy, I will eat a snack instead of lunch.
137.
Sometimes I eat dessert more than once a day.
138.
I reduce fat in recipes by substituting ingredients and cutting portions.
139.
I have a sweet tooth.
140.
I sometimes snack even when I am not hungry.
141.
I eat out because it is more convenient than eating at home.
142.
I hate to cook.
143.
I would rather buy take-out food and bring it home than cook.
144.
I have at least three to four servings of vegetables a day.
145. To me, cookies are an ideal snack food.
146.
My eating habits are very routine.
147.
If I do not feel hungry, I will skip a meal even if it is time to eat.
148.
When choosing fast food, I pick a place that offers healthy foods.
149.
I eat at a fast food restaurant at least three times a week.
Strongly
Disagree a
Disagree Neutral
N/A b c
Agree Strongly
Agree d e a a a a a a a a a a a a a a a a a a a a a e e e e e e e e e e e d d d d d d d d d d d c c c c c c c c c c c b b b b b b b b b b b b b b b b b b b b b d d d d d d d d d d c c c c c c c c c c e e e e e e e e e e
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We are interested in finding out about the kinds of physical activities that people do as part of their everyday lives. The questions will ask you about the time you spent being physically active in the last 7 days.
Please answer each question even if you do not consider yourself to be an active person.
Please think about the activities you do at work, as part of your house and yard work, to get from place to place, and in your spare time for recreations, exercise or sport.
Think about all the vigorous activities that you did in the last 7 days .
Vigorous physical activities refer to activities that take hard physical effort and make you breathe much harder than normal. Think only about those physical activities that you did for at least 10 minutes at a time.
150.
During the last 7 days , on how many days did you do VIGOROUS physical activities like heavy lifting, digging, aerobics, or fast bicycling? a.
number of days _________ b.
no vigorous physical activity
151.
How much time did you usually spend doing VIGOROUS physical activities on one of those days? a.
________ hours ________minutes b.
don’t know, not sure c.
no vigorous physical activity
Think about all the moderate activities that you did in the last 7 days .
Moderate activities refer to activities that take moderate physical effort and make you breathe somewhat harder than normal. Think only about those physical activities that you did for at least 10 minutes at a time.
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152. During the last 7 days , on how many days did you do MODERATE physical activities like carrying light loads, bicycling at a regular pace, or doubles tennis? Do not include walking. a.
number of days_____________ b.
no moderate physical activity
153.
How much time did you usually spend doing MODERATE physical activities on one of those days? a.
_________ hours _________minutes b.
don’t know, not sure c.
no moderate physical activity
Think about the time you spent walking in the last 7 days . This includes at work and at home, walking travel from place to place, and any other walking that you might do solely for recreation, sport, exercise, or leisure.
154.
During the last 7 days , on how many days did you WALK for at least
10 minutes at a time? a.
number of days___________ b.
no walking
155.
How much time did you usually spend walking on one of those days? a.
__________hours__________minutes b.
don’t know, not sure c.
no walking
The next question is about the time you spent sitting on weekdays during the last 7 days . Include time spent at work, at home, while doing course work and during leisure time. This may include time spent sitting at a desk, visiting friends, reading, or sitting or lying down to watch television or play video games.
156.
During the last 7 days , how much time did you spend sitting on a week day ? a.
__________hours _________minutes b.
don’t know, not sure c.
no walking
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Many factors in our life determine our ability and desire to be physically active.
Select the level at which the following factors influence your exercise patterns.
Influence on My Exercise Patterns
Positive Influence No Influence Negative Influence
157.
Significant Other
158.
Children
159.
Other family members
160.
Job/Profession/School
161.
Desire to be “in shape” or more attractive
162.
Time
163.
Energy Level
164.
Finances
165. Desire to be healthy a a a a a a a a a b b b b b b b b b c c c c c c c c c
Today people engage in various activities to lose weight or get in shape. In this section, we would like to know which of the following body parts would you like to change or stay the same.
Please think of each of the following parts of your body and tell us if you would like them to be bigger, smaller, or stay the same. Circle the appropriate answer.
166. ARMS BIGGER SMALLER STAY THE SAME SIZE
167. STOMACH
168. CHEST
169. HIPS
170. THIGHS
171. BUTTOCKS
172. LEGS
BIGGER
BIGGER
BIGGER
BIGGER
BIGGER
BIGGER
SMALLER
SMALLER
SMALLER
SMALLER
SMALLER
SMALLER
STAY THE SAME SIZE
STAY THE SAME SIZE
STAY THE SAME SIZE
STAY THE SAME SIZE
STAY THE SAME SIZE
STAY THE SAME SIZE
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Circle the number that best describes the body shape of your family members (currently, or the last time that you saw them).
173. Mother
Overweight Normal a
Weight b
Underweight c
Not
Applicable d
174. Father
175.
Mother’s Mother
176.
Mother’s Father
177.
Father’s Mother
178.
Father’s Father
179. Your significant other a a a a a a b b b b b b c c c c c c d d d d d d
Please circle the number that best describes your own body shape.
Overweight Normal
Weight
Underweight
I Don’t Know
180. As a young child a b c d
181. As a teenager a b c d
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Next, we would like to ask you about other issues that affect health. Please circle the appropriate choice or fill in the appropriate blank.
First, a few questions about your race and how others react to your race.
182.
What is your race/ethnicity? a.
White b.
Black or African American c.
Hispanic or Latino d.
Asian e.
Native Hawaiian or Other Pacific Islander f.
American Indian or Alaska Native g.
Biracial/Multiracial h.
Don’t know/Not sure
183.
How do other people usually classify you in this country? a.
White b.
Black or African American c.
Hispanic or Latino d.
Asian e.
Native Hawaiian or Other Pacific Islander f.
American Indian or Alaska Native g.
Biracial/Multiracial h.
Don’t know/Not sure
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184.
How often do you think about your race? a.
Never b.
At least once a year c.
At least once a month d.
At least once a week e.
At least once a day f.
At least once an hour g.
Constantly h.
Don’t know
185.
During the past 12 months, on average were you treated better than, worse than, or the same as people of other races? a.
Better than b.
Worse than c.
The same as d.
don’t know/Not sure
184.
During the past 30 days, have you felt emotionally upset (for example angry, sad, or frustrated) as a result of how other people were treated based on their race? a.
Yes b.
No c.
Don’t know/Not sure
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The next set of questions is about religion and spirituality in your life.
More than
Once a Week a
Every Week or
More Often b
Once or Twice a Month c
Every Month or so d 185. How often do you go to religious services?
186.
187. How religious are you?
188.
189. How spiritual are you?
Very Religious Moderately
Religious a b
Very Spiritual Moderately
Spiritual a b
Slightly
Religious c
Slightly
Spiritual c
Not Religious at All d
Not Spiritual at All d
Once or Twice a Year e
Don’t
Know e
Don’t
Know e
Don’t
Know f
The next questions deal with possible spiritual experiences. How often do you experience the following:
190.
I feel God’s presence
191. I find strength and comfort in my religion
192. I feel deep inner peace and harmony
193. I desire to be closer or in union with God
194.
I feel God’s love for me, directly or through others
195. I am spiritually touched by the beauty of creation
Many times a day a a a a a a
Every day b b b b b b
Most days c c c c c c
Some days d d d d d d
Once in a while e e e e e e
Never or almost never f f f f f f
How often do you do the following things:
More than once a day a
Once a day b
A few times a week c
Once a week d
A few times a month e
Less than once a month f
Once a month g 196. How often do you pray privately in places other than at church or synagogue?
197. Within your religious or spiritual tradition, how often do you meditate?
198. How often do you read the Bible or other religious literature?
199. How often are prayers or grace said before or after meals in your home? a a a b b b c c c d d d e e e f f f g g g
Don’t
Know g g g g g g
Never
Don’t
Know h h h h i i i i
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The questions in this scale ask you about your feelings and thoughts during the last month. In each case, you will be asked to indicate how often you felt or thought a certain way. For each question choose from the following alternatives: never, almost never, sometimes, fairly often, very often.
Never a
Almost
Never b
Sometimes Fairly
Often c d
Very
Often e
Don’t
Know f 200. In the last month, how often have you been upset because of something that happened unexpectedly?
201. In the last month, how often have you felt that you were unable to control the important things in your life?
202. In the last month, how often have you felt nervous and
“stressed”?
203. In the last month, how often have you dealt successfully with initiating life hassles?
204. In the last month, how often have you felt that you were effectively coping with important changes that were occurring in your life?
205. In the last month, how often have you felt confident about your ability to handle your personal problems?
206. In the last month, how often have you felt that things were going your way?
207. In the last month, how often have you found that you could not cope with all the things that you had to do?
208. In the last month, how often have you been able to control irritations in your life?
209. In the last month, how often have you felt that you were on top of things?
210. In the last month, how often have you been angered because of things that were outside your control?
211. In the last month, how often have you found yourself thinking about things that you have to accomplish?
212. In the last month, how often have you been able to control the way you spend your time?
213. In the last month, how often have felt difficulties were piling up so high that you could not overcome them? a a a a a a a a a a a a a b b b b b b b b b b b b b c c c c c c c c c c c c c d d d d d d d d d d d d d e e e e e e e e e e e e e f f f f f f f f f f f f f
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The next set of questions asks about your emotional well-being. Circle the appropriate box.
214. My appetite was poor
215. I could not shake off the blues
216. I had trouble keeping my mind on what I was doing
217. I felt depressed
218. My sleep was restless
219. I felt sad
220. I could not get going
221. Nothing made me happy
222. I felt like a bad person
223. I lost interest in my usual activities
224. I slept much more than usual
225. I felt like I was moving too slowly
226. I felt fidgety
227. I wish I were dead
228. I wanted to hurt myself
229. I was tired all the time
230. I did not like myself
231. I lost a lot of weight without trying to
232. I had a lot of trouble getting to sleep
233. I could not focus on the important things
234.
I was bothered by things that usually don’t bother me
235. I felt that I was just as good as other people
236. I felt that everything I did was an effort
237. I felt hopeful about the future
238. I thought my life had been a failure
239. I felt fearful
240. I was happy
241. I talked less than usual
242. I felt lonely
243. People were unfriendly
244. I enjoyed life
245. I had crying spells
Not at all
(0 days) a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a
Occasionally
(3-4 days) c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c
Some days
(1-2 days) b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b
Most days
(5-7 days) d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d
Nearly every day
(10-14 days) e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e
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246. I had a lot of fun
247. I felt like I might as well give up
248. I felt like people disliked me
Not at all
(0 days) a a a
Some days
(1-2 days) b b b
Occasionally
(3-4 days) c c c
Most days
(5-7 days) d d d
Nearly every day
(10-14 days) e e e
The next set of questions is related to your exposure and experience with drugs and alcohol.
If you have ever used at least one of the following substances, select the appropriate response for the substance.
No, never
249. Cigarettes/tobacco products
250. Beer
251. Wine/wine cooler
252. Hard liquor
Yes, on a regular basis a a a a
Yes, but only occasionally, at social events b b b b
I used to, but stopped c c c c d d d d
For those who drink alcoholic beverages:
253. Have you ever felt the need to cut down on drinking?
254. Have you ever felt annoyed by criticisms of your drinking?
255. Have you ever had guilty feelings about drinking
256. Have you ever taken a morning eye opener? That is you needed a drink just after you woke up?
257 Have you ever gone to the emergency room as a result of using alcohol?
Yes No
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At what age did you first have an OPPORTUNITY TO TRY any of the following? By try we are referring to the first time any of these substances were made available to you, either in the home where you lived, or offered to you by someone else. (Answer one appropriate box for each category)
Age of 1 st opportunity (in years) Never
258. Cigarettes/tobacco products
259. Beer
260. Wine/Wine cooler
261. Hard liquor
262. Marijuana
263. Powder cocaine (sniffed)
264. Cocaine (injected)
265. Crack/rock cocaine
266. Cadrina (beyond medical advice or without prescription)
267. Sedatives (beyond medical advice or without prescription)
268. Amphetamines (beyond medical advice or without prescription
269. Barbiturates (beyond medical advice or without prescription)
270. Heroin
271. Any other opiate (beyond medical advice or without prescription)
At what age did you FIRST ACTUALLY USE any of these substances? (Answer one appropriate box for each category)
Age of 1 st Time Use (in years) Never
272. Cigarettes/tobacco products
273. Beer
274. Wine/Wine cooler
275. Hard liquor
276. Marijuana
277. Powder cocaine (sniffed)
278. Cocaine (injected)
279. Crack/rock cocaine
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OS03
280. Cadrina (beyond medical advice or without prescription)
281. Sedatives (beyond medical advice or without prescription)
282. Amphetamines (beyond medical advice or without prescription
Age of 1 st Time Use (in years) Never
283. Barbiturates (beyond medical advice or without prescription)
284. Heroin
Within the past 30 days, on how many days did you use any of the following? (Note: The number should be less than or equal to 30). Enter “0” if not used at all.
285. Cigarettes/tobacco products
286. Beer
287. Wine/Wine cooler
288. Hard liquor
289. Marijuana
290. Powder cocaine (sniffed)
291. Cocaine (injected)
292. Crack/rock cocaine
293. Cadrina (beyond medical advice or without prescription)
294. Sedatives (beyond medical advice or without prescription)
295. Amphetamines (beyond medical advice or without prescription
296. Barbiturates (beyond medical advice or without prescription)
297. Heroin
Number of days
Answer the next six questions only if you currently smoke.
298. How soon after you wake up do you smoke your first cigarette
(cigar/pipe)? a. Within 5 minutes b. Within 6-30 minutes c. Within 31-60 minutes d. More than one hour
299. Do you find it difficult to refrain from smoking in places where it is forbidden to smoke-for example, in church, at the library, in the movie theater, or in no smoking sections of restaurants or office buildings? a. Yes b. No
300. Which cigarettes (cigar/pipe) would you hate most to give up? a.
The first one in the morning
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OS03 b.
All others c.
Don’t know
301. How many cigarettes (cigars/pipes) do you now smoke each day? a. b. c. d.
1-10
11-19
20 (=one pack)
21-30 e. f. g. h.
31-39
40 (=2 packs)
More then 40
Don’t know
302. Do you smoke more frequently during the first hours after waking than during the rest of the day? a.
Yes b.
No c.
Don’t know
303. When you are so ill that you are in bed most of the day, do you smoke? a.
Yes b. No c. Don’t Know
For the following section please define:
304.
What is your sexual preference? a.
Opposite sex b.
c.
d.
Same sex
Doesn’t matter
Don’t know
Please circle the response that best describes how often in the past year you and your partner have used these behaviors when dealing with each other. If you have NOT been in a relationship for the past year, SKIP to Question No. 324
Never
305. Discussed the issue calmly
306. Got information to back up (your/his/her) side of things
307. Brought in or tried to bring in someone to help settle things
308. Argued heatedly but short of yelling
309. Insulted, yelled or swore at the other one
310. Sulked and/or refused to talk about it
311. Stomped out of the room or house (or yard)
312. Cried a a a a a a a a
Seldom
1-10 times per year b b b b b b b b
Often
More than 10 times per year c c c c c c c c
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OS03
313. Did or said something to spite the other one
314. Threatened to hit or throw something at the other one
315. Threw something at the other one.
316. Threw or smashed or hit or kicked something
317. Pushed, grabbed, or shoved the other one
318. Slapped the other one
319. Kicked, bit or hit with a fist
320. Hit or tried to hit with something
321. Beat up the other one
322. Threatened with a knife or gun
323. Used a knife or gun a
Never a a a a a a a a a a b
Seldom
1-10 times per year b b b b b b b b b b c
Often
More than 10 times per year c c c c c c c c c c
In this final section, we are interested about your utilization of health care. Please circle appropriate responses to the questions below.
324. What type of health insurance do you currently have? a. b.
Group health insurance through my employer or the military
I am covered on a family member’s plan c. d.
I do not have health insurance
I participate in a medical assistance program such as
Medicaid
325.
In the last 12 months, have you visited a doctor or medical clinic for any reason, including check-ups or visits to the emergency room or hospital outpatient department? a. b.
326.
In the last 12 months, have you been admitted to the hospital? a. b.
Yes
No
Yes
No
327.
In the last 12 months, have you been to the dentist? a. b.
Yes
No
328.
Where do you usually go when you are sick or need health care? a. Doctor’s office or private clinic b. c. d. e.
Community health center or other public clinic
Hospital outpatient department
Hospital emergency room
Some other place f. g.
School health clinic
No regular place of care
329.
During the past 12 months, how did you communicate with a doctor, nurse, counselor or other medical person about your health? a.
During an office visit b.
By telephone c.
By email d.
I did not speak to a medical person about my health
330.
During the last 12 months, was there any time when you had a medical problem but put off, postponed or did not seek medical care when you needed to? a.
Yes
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OS03 b.
No
331.
If you did postpone seeking medical care, what was the reason? a. b. c.
Cost
Time other
332.
During the last 12 months, was there any time when you did not fill a prescription for medicine? a.
Yes b.
No
333.
If you did not fill a prescription what was the reason? a.
Cost b.
Time c.
Other
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